Smaller rectus femoris size measured by ultrasound is associated with poorer outcomes after cardiac surgery.

OBJECTIVE: We sought to evaluate the association of low rectus femoris cross-sectional area (RFCSA) with hospital length of stay and poorer outcomes in patients undergoing cardiac surgery. METHODS: A single right-leg RFCSA was measured with ultrasound preoperatively and baseline characteristics, clinical data, and outcomes recorded. Patients were categorized as low rectus femoris muscle size (lowRF) or normal rectus femoris muscle size (normalRF), if they were in the lowest quartile or not, respectively. All analyses were performed on both body surface area (BSA)- and sex-adjusted RFCSA. RESULTS: One hundred eight-four patients had a RFCSA measured with a mean of 5.01 cm2 (1.41 cm2), and range of 0.71 to 8.77 cm2. When analyzing the BSA-adjusted RFCSA, we found the lowRF group had a longer hospital stay, 11.0 days [7.0-16.3] versus 8.0 days [6.0-10.0] for the normalRF group (P < .001), and a greater proportion of extended hospital stay (≥18.5 days) of 19.6% compared with 6.2% (P = .010). When the RFCSA was adjusted for sex, the lowRF group had a greater length of hospital stay, 9.0 days [7.0-14.5] versus 8.0 days [6.0-11.0] (P = .049). In both the BSA- and sex-adjusted RFCSA, the lowRF group suffered greater morbidity and were more likely discharged to a destination other than home. In multivariate analyses adjusting for European System for Cardiac Operative Risk Evaluation II, BSA-adjusted lowRF but not sex-adjusted lowRF was independently associated with log-transformed hospital length of stay. LowRF was not independently associated with increased major morbidity and death for both BSA and sex-adjusted RFCSA. CONCLUSIONS: Low RFCSA has a significant association with increased hospital length of stay, morbidity, and nonhome discharge in patients undergoing cardiac procedures. TRIAL REGISTRY NUMBER: ACTRN12620000678998.

Transesophageal echocardiography in thoracic anesthesia: pulmonary hypertension and right ventricular function.

PURPOSE OF REVIEW: Pulmonary hypertension is associated with increased postoperative morbidity and mortality. Early diagnosis and echocardiographic detection of right ventricular (RV) dysfunction are paramount in perioperative management. The goal of this review is to provide an overview of the recent literature on this topic. RECENT FINDINGS: Doppler interrogation of pulmonary artery flow may provide an insight into the severity and mechanism of pulmonary hypertension. Established echocardiographic techniques of RV assessment have multiple limitations. Newer echocardiographic technologies (strain and three-dimensional imaging) are promising, but require further validation in the perioperative setting before they are adopted. SUMMARY: More pulmonary hypertension patients are presenting for noncardiac surgery, creating a challenge for the anesthesiologist. Echocardiographic detection of RV dysfunction can be difficult. Routine use of intraoperative transesophageal echocardiography in major thoracic surgery is not advocated yet, but the development of automated techniques may provide an objective assessment of RV function.

Selective ß1-antagonism with bisoprolol is associated with fewer postoperative strokes than atenolol or metoprolol: a single-center cohort study of 44,092 consecutive patients.

BACKGROUND: Perioperative metoprolol increases postoperative stroke. Animal studies indicate that the mechanism may be related to attenuated ß(2)-adrenoreceptor-mediated cerebral vasodilatation. The authors therefore conducted a cohort to study whether the highly ß(1)-specific ß-blocker (bisoprolol) was associated with a reduced risk of postoperative stroke compared with less selective ß-blockers (metoprolol or atenolol). METHODS: The authors conducted a single-center study on 44,092 consecutive patients with age 50 yr or more having noncardiac, nonneurologic surgery. The primary outcome was stroke within 7 days of surgery. The secondary outcome was a composite of all-cause mortality, postoperative myocardial injury, and stroke. A propensity score-matched cohort was created to assess the independent association between bisoprolol and less ß(1)-selective agents metoprolol or atenolol. A secondary analysis using logistic regression, based on previously identified confounders, also compared selective ß(1)-antagonism. RESULTS: Twenty-four percent (10,756) of patients were exposed to in-hospital ß-blockers. A total of 88 patients (0.2%) suffered a stroke within 7 days of surgery. The matched cohort consisted of 2,462 patients, and the pairs were well matched for all variables. Bisoprolol was associated with fewer postoperative strokes than the less selective agents (odds ratio = 0.20; 95% CI, 0.04-0.91). Multivariable risk-adjustment in the ß-blockers-exposed patients comparing bisoprolol with the less selective agents was associated with a similarly reduced stroke rate. CONCLUSIONS: The use of metoprolol and atenolol is associated with increased risks of postoperative stroke, compared with bisoprolol. These findings warrant confirmation in a pragmatic randomized trial.